Evidence Of Venous Insufficiency Research Articles

Comorbidity of hypertension and chronic venous disease in men

Aim. To study the clinical manifestations and characteristics of lower extremity chronic venous disorders (CVD) in working-age men with hypertension (HTN).Material and methods. The study included 74 men with HTN at the age of 30-50 years and 41 men without HTN. HTN duration and regularity of antihypertensive medication intake were studied. We analyzed complaints and objective signs associated with CVD, their severity, structural and functional parameters of superficial, deep and perforator veins of the lower extremities using the triplex ultrasound. The prevalence and severity of cardiovascular risk factors among patients with HTN and CVD and patients with HTN and without CVD were analyzed.Results. Men aged 30-50 with HTN showed a high prevalence of complaints (68%) associated with CVD: evening heaviness and fullness in the legs; pain decrease at rest; a combination of pain, spasm and swelling in long-time standing. Objective signs of CVD were recorded in 83,8% of men with HTN (most often — telangiectasia (38%) and swelling (24%)). Men with HTN were diagnosed with more severe manifestations of CVD than men without HTN. In patients with HTN, episodic pain and evening perimalleolar swelling were 1,8 and 4 times more likely, respectively, than in men without HTN. The presence of CVD and HTN was not associated with cardiovascular risk factors. HTN in men was characterized by a large-diameter veins, pathological reflux, vein tortuosity, the presence of thrombotic masses and postthrombotic lesions. In patients with HTN, along with an increased blood flow velocity in the deep and perforator veins of the lower leg, a low velocity in the deep femoral veins was observed. This is the evidence of venous insufficiency even at rest. Orthostasis in men with HTN increased the frequency of reflux in superficial veins by 2-4 times, which proves latent venous insufficiency.Conclusion. HTN is characterized by an increase in the frequency and severity of symptoms and signs of CVD, which indicates their comorbidity.

Effects of Surgery on Microvascular Function in Venous Insufficiency

The aim of our study was to assess the effects of venous stripping on microvascular functions in isolated great saphenous vein insufficiency. Two groups of participants were prospectively evaluated. The first group included 15 healthy participants without any evidence of venous insufficiency. The second group included 20 patients with varicose veins because of great saphenous vein insufficiency. The demographics, venous clinical severity scores, and CEAP classifications of the patients were recorded. Next, all individuals underwent evaluations for microvascular vasoreactivity using an iontophoretic laser Doppler imager, and the outcomes were recorded. Patients with varicose veins underwent stripping surgeries, and microvascular vasoreactivity evaluations were repeated 6 weeks postoperatively. There was a statistically significant decrease in the patients with varicose veins compared with the control group in response to nitroprusside (SNP) applied at 4 mC in the supine position. Furthermore, there was also a significant difference in the response to acetylcholine (ACh) in patient group in the sitting position (P < 0.05). We also observed a statistically significant decrease in the responses to SNP applied for 1, 2, and 4 mC (P < 0.05) in the patients in the sitting position. The relief of pain and edema after surgery was found to be significant (P < 0,001). In the subgroup in which ACh was applied for 1 and 4 mC in the supine position, postoperative microvascular flow was significantly increased (P < 0.005). Moreover, based on the measurements taken in the supine position, the patients in the subgroup in which SNP was applied for 1, 2, or 4 mC exhibited significantly increased postoperative microvascular dilatation (P < 0.005). Saphenous vein insufficiency impairs the endothelium-dependent vasodilatation response in the perimalleolar region, and partial recoveries in microvascular function were observed after surgical treatment.

Reproducibility of Duplex Ultrasonography and Air Plethysmography Used for the Evaluation of Chronic Venous Insufficiency

The purpose of this study was to determine the reproducibility of measurements on duplex ultrasonography (DU) and air plethysmography (APG) in subjects with post-thrombotic syndrome. Duplex ultrasonography and APG were used to measure indices of lower limb venous reflux in 15 limbs with a history of deep vein thrombosis and evidence of venous insufficiency as diagnosed by ultrasonography. Three limbs were in class 0; 4 were in classes 1 to 3; and 8 were in classes 4 to 6, according to clinical, etiologic, anatomic, and pathophysiologic clinical classification. Duplex ultrasonography was performed 3 times on the same day, and venous diameter, area, peak reflux velocity, reflux flow volume, and reflux duration measurements were obtained. Air plethysmography was performed on 2 days, 7 to 10 days apart, with 1 measurement on the first day and 2 measurements on the second day. Values obtained from APG included outflow fraction, venous filling index, ejection fraction, and residual volume fraction. The measurements were performed by a vascular technologist blinded to the previous test results. One-way analysis of variance, the Student paired t test, and Bland-Altman plots were used to examine the statistical differences of the DU and APG parameters for all measurements. The mean coefficient of variation for within-subject measurements of all DU and APG parameters measured was less than 10%. Bland-Altman plots showed that there were no apparent trends with increasing values over a wide range for any of the DU parameters, nor were there any for the APG parameters. Under ideal conditions, when measured by a highly trained technologist, both DU and APG showed satisfactory reproducibility.

Cutaneous polyarteritis nodosa in patients presenting with atrophie blanche.

The term 'atrophie blanche' is used both as a descriptive term denoting ivory-white stellate scars on the lower limbs as well as a diagnostic label synonymous with livedoid vasculitis, an ill-defined entity. Medium-sized vasculitides, such as polyarteritis nodosa (PAN), occasionally present with ulceration resulting in ivory-white stellate scarring on the lower limbs and may potentially be misdiagnosed as livedoid vasculitis. To assess the occurrence, clinical and immunopathological features of medium-sized vasculitis in patients presenting with atrophie blanche without clinical and/or compression duplex ultrasonographic evidence of venous insufficiency. We retrospectively evaluated patients presenting with atrophie blanche at the Department of Dermatology of Johns Hopkins Medical Institutions, from April 1996 until April 2002, following the diagnostic guidelines for leg ulcers of the Division of Immunodermatology. Deep and multiple skin biopsies were performed for histology. Investigations for underlying vasculitis, thrombophilia, nerve conduction studies and compression duplex ultrasonography of the lower extremities were performed in all patients. Of 29 consecutive patients presenting with atrophie blanche, six had underlying medium-sized vasculitis consistent with PAN, three of whom had previously been diagnosed to have segmental hyalinizing vasculitis/vasculopathy (livedoid vasculitis/vasculopathy) on superficial biopsies. All six patients with cutaneous PAN were women with a median age of 36.5 years (range 34-46) and with a median duration of the disease prior to diagnosis of 18 years (range 3-30). Of the six cutaneous PAN patients, four had neurological involvement evidenced by clinical symptoms and nerve conduction studies. No evidence of any other extracutaneous involvement was found. Erythrocyte sedimentation rate and tests for vasculitis and thrombophilic were normal in all six patients. None had evidence of venous insufficiency. Immunosuppressive therapy was effective in controlling PAN-associated cutaneous and neurological disease. Of the remaining 23 patients, two had antiphospholipid syndrome and one had homocystineaemia; all three also had evidence of venous insufficiency. One patient had multiple myeloma-associated type I cryoglobulinaemia and 19 patients had venous insufficiency alone. None of the non-PAN patients had abnormalities in the nerve conduction studies. In patients presenting with atrophie blanche without evidence of venous insufficiency and thrombophilia, PAN should be excluded, particularly in the presence of mononeuritis multiplex. Repeated and deep biopsies are often necessary to reveal the accurate underlying pathology of necrotizing medium-sized vasculitis in the reticular dermis and the subcutis, especially in the setting of atrophie blanche lesions. Immunosuppressive therapy was effective in controlling the PAN-associated clinical manifestations.

Does severe venous insufficiency have a different etiology in the morbidly obese? Is it venous?

Chronic venous insufficiency (CVI) is the most common cause of leg ulcers. Patients with morbid obesity are remarkable for particularly recalcitrant ulcers. Because obesity is not specifically incorporated in CEAP or other venous scoring systems, we sought to characterize this group of patients more completely. Patients with severe CVI (CEAP clinical class, 4, 5, and 6), and class III obesity (body mass index [BMI], >40) were reviewed. Findings from clinical and duplex ultrasound scan (DU) examinations were compared with the CEAP classification, its adjunctive venous clinical severity score, and sensory thresholds. A review of clinic records identified 20 ambulatory patients with a mean age of 62 years, a mean BMI of 52, and a mean weight of 164 kg (361 lbs); all but one had bilateral symptoms. No evidence of venous insufficiency was detected with DU in 24 of the 39 limbs. Although some valvular incompetence was detected with DU in 15 of 39 limbs, these abnormalities were widely dispersed between 28 sites; eight limbs had findings at only one site. Ulceration (mean area, 29 cm(2)) was present in 25 limbs and necessitated 7 months for healing; 13 (52%) recurred at least once during a mean observation period of 36 months. The mean sensory threshold of 5.21 exceeded current risk thresholds used in diabetic screening programs. The distribution of CEAP clinical class was C4 (n = 14), C5 (n = 14), and C6 (n = 11). Increasing CEAP class correlated with an increased mean BMI of 47, 52, and 56, respectively (P <.01). CEAP also correlated with a rising mean venous clinical severity score of 10, 11, and 15, respectively (P <.05). Patients with class III obesity had severe limb symptoms, typical of CVI, but approximately two thirds of the limbs had no anatomic evidence of venous disease. The association of increasing limb symptoms with increasing obesity suggested that the obesity itself contributes to the morbidity.

Phlegmasia Cerulea Dolens in a Patient with Ulcerative Colitis Treated by Iliofemoral Venous Thrombectomy

The authors present the case of a 17-year-old woman with ulcerative colitis who presented with phlegmasia cerulea dolens (PCD) of the right leg. On examination, the compartments of her right leg were tense, sensory and motor function were greatly diminished, and pedal pulses were absent. Venous duplex revealed extensive venous thrombosis from the tibial veins to the external iliac vein. Treatment consisted of anticoagulation with systemic heparinization, and she was brought to the operating room for intraoperative venography, inferior vena caval filter placement, and four-compartment fasciotomy. Arterial pulses did not return; therefore, venous thrombectomy was performed by extrusion of distal thrombus with an Esmarch bandage, and fluoroscopic guided balloon catheter thrombectomy of the distal inferior vena cava and iliac veins proximally. Completion venography revealed the absence of residual thrombus. Postoperatively, the patient developed a lower gastrointestinal hemorrhage and anticoagulation was terminated. The fasciotomy skin incisions underwent delayed closure on postoperative day 6, and the patient was subsequently discharged with compression stockings. Total abdominal colectomy with creation of a J-pouch was performed 1 month following discharge. After 1 year, the patient had no complaints related to her leg. On examination, no evidence of venous insufficiency was present. Venous duplex demonstrated a patent deep venous system with no evidence of reflux. Uncomplicated PCD responds to heparin therapy in 50-80% of patients, but the risk for developing the postphlebitic syndrome is high. Venous thrombectomy has been reported to provide better long-term functional outcome. Catheter-directed thrombolysis has the added theoretical benefit of preserving endothelial and valvular function, and high technical success rates have been reported. No long-term functional outcome results for thrombolysis are available. Thrombolysis is contraindicated if compartment syndrome or venous gangrene is present. The aggressive surgical management of PCD may result in improved outcome.

The Effects of Varicose Vein Surgery on the Venous Function of the Lower Limb

Objectives: To assess the effect of varicose vein surgery on the venous function of the lower limb and to determine the ability of strain-gauge and photoplethysmography in discriminating between normal and abnormal venous function. Design: Prospective randomized trial with follow-up to 1 month postoperatively. Study group: Fifteen patients presenting for varicose vein surgery and 10 controls with no evidence of venous insufficiency. Interventions: Venous investigations were carried out preoperatively and at 1 month postoperative appointments. Main outcome measures: The effect of varicose vein surgery on lower limb venous function and the ability of plethysmography to distinguish normal from abnormal venous function. Results: Significant differences were found between pre- and postoperative venous refilling times (VRT) in patients attending for varicose vein surgery ( p&gt;&lt;0.01). Significant differences were also found between control and case preoperative VRTs. No significant differences were found between pre- and postoperative, and case/control venous outflow (VO) and venous capacitance (VC) values. Conclusion: Varicose vein surgery improved the venous function in all of the lower limbs investigated. Photoplethysmographic venous refilling times were found to be a useful, reproducible measure, able to distinguish normal from abnormal venous function.

Comparison of Clinical and Photoplethysmographic Assessment of Venous Insufficiency

Objective: To assess the concordance between clinical and photoplethysmographic evaluation of venous insufficiency. Design: Comparison of two methods of evaluation of venous insufficiency in randomly selected patients. Setting: The Vascular Institute, Shaare Zedek Hospital, Jerusalem, Israel. Patients: Four hundred patients selected at random from a pool of 3000 patients referred to the vascular institute for suspected venous insufficiency. Interventions: Each of the 800 legs was evaluated clinically, by Trendelenburg testing, and by venous reflux photoplethysmography (VPPG). Results: Of 230 legs without clinical evidence of venous insufficiency (including Trendelenburg testing), 214 (93%) were also normal by VPPG. However, of 359 legs with clinical evidence of venous insufficiency, only 178 (50%) were so confirmed by VPPG. Of 135 legs considered to have insufficiency of the deep venous system (DVI) by clinical criteria alone, only 31 (23%) were confirmed to have DVI by VPPG, and 49 (36%) were found by VPPG to have insufficiency of only the superficial system. Conclusions: Reliance upon clinical assessment alone is inadequate for distinguishing between insufficiency of the deep and superficial or perforating venous systems. Assessment by VPPG may identify many patients with dermatologic changes “typical of DVI” who may benefit from superficial venous surgery.

The role of air plethysmography in monitoring results of venous surgery

The development of an objective, noninvasive method to assess the hemodynamic effects of venous surgery has long been awaited. Previous methods used to evaluate the results of surgery for varicose veins and venous stasis ulceration have been limited in their quantitative assessment. Now, by use of air plethysmography (APG), we can accurately quantify the effectiveness of corrective venous surgery. Twenty-five extremities that had evidence of venous insufficiency were examined with use of APG before and after venous surgical procedures. Surgery was directed at specific sites of venous incompetence as defined by physical examination and high-resolution duplex imaging. Twenty-one extremities underwent ligation and stripping of the greater saphenous vein. In these patients, APG showed an improvement in venous reflux as demonstrated by a decrease in the venous filling index from 6.6 ± 0.7 ml/sec to 1.8 ± 0.3 ml/sec (p = 0.0001) and venous volume from 177.1 ± 14.5 ml to 139.2 ± 8.9 ml (p = 0.0008). In addition, these patients showed a mild improvement in calf muscle pump function as noted by an improvement in ejection fraction from 45.8% ± 2.0% to 50.8% ± 2.5% (p = 0.07). The residual volume fraction decreased from 45.0% ± 3.4% to 42.0% ± 3.7%, a difference that was not statistically significant (p = 0.4). Four extremities with grade III chronic venous insufficiency underwent popliteal vein valve transplantation with use of an autogenous axillary vein valve. Venous reflux in these patients was reduced dramatically in the early postoperative period, with the venous filling index dropping from 14.2 ± 2.3 ml/sec before the operation to 5.1 ± 1.4 ml/sec after the operation (p = 0.08) in conjunction with a drop in venous volume from 190.9 ± 35.4 ml to 135.2 ± 10.7 ml (p = 0.15). APG offers a unique and quantitative technique to evaluate the results of reconstructive venous surgery. It is simple and noninvasive, and we believe it represents an improvement on older methods for evaluating the effect of surgery on the venous hemodynamics of the leg.

Varicose Veins: A Clinical and Biochemical Correlation

Prostaglandin (PG) metabolism in chronic venous disease can be assessed by quantitative analysis of prostacyclin (PGI2, an antiaggregatory vasodilator) and thromboxane A2 (TXA2, a proaggregatory vasoconstrictor). The authors corre lated the biochemical and noninvasive evaluation (Doppler ultrasound, pho toplethysmography [PRG], and phleborheography [PRG]) of 20 patients with normal and varicose veins, using operative specimens for biochemical analysis. Ten-mg segments of vein were incubated with 10 μM 14C-PGH2 and separated by thin-layer chromatography. Formation of 6-keto-PGF1a and TXB2 was in creased in varicose vein compared with normal vein: 157 ± 11 vs 230 ± 19 picograms 6-keto-PGF1a (p &lt;.05) and 23 ± 2 vs 34 ± 4 picograms TXB2 (p &lt;.05). All patients with varicose veins displayed evidence of venous insufficiency by all examinations. Of 13 patients with clinically normal veins, 8 were normal by all noninvasive criteria. Five were abnormal by two or more noninvasive critera, yet had normal biochemical findings. Increased PGI2 formation in patients with varicose veins indicated increased activity of PGI 2 synthase, possibly associated with chronic venous insufficiency . Noninvasive testing may indicate those patients at risk for developing chronic venous disease before clinical or biochemical changes occur.